This Is Not a Drill

When Disaster Strikes, Caregivers Spring into Action

As a surgeon at Brigham and Women’s Hospital in Boston and associate director of its Center for Surgery and Public Health, Dr. Atul Gawande knows a little something about how hospitals respond to emergencies.
And as a staff writer for the New Yorker, he was able to share some of that insight after twin explosions rocked the Boston Marathon last month, killing three people almost instantly and injuring more than 250 others, all of whom survived.
“They had their limbs blown off, vital arteries severed, bones fractured, flesh torn open by shrapnel or scorched by the blasts’ heat,” he wrote the day after the terrorist attack. “Yet, it now appears that every one of the wounded alive when rescuers reached them will survive. Medically speaking, this is no small accomplishment.”
He noted that, within minutes, the runners’ first-aid tent was converted to a mass-casualty triage unit, and emergency medical teams mobilized en masse throughout Boston, resuscitated the injured, dispersed them to eight different hospitals, despite the chaos and snarled traffic.
“How did this happen?” he asked. “Something more significant occurred than professionals merely adhering to smart policies and procedures. What we saw unfold was the cultural legacy of the Sept. 11 attacks and all that has followed in the decade-plus since. We are not innocents anymore.”
Gawande’s words resonate with Brian Rust, manager of Security Services at Cooley Dickinson Hospital.
“My philosophy has always been to steer away from the complexity of information-management systems and all this other stuff that sounds good when you get a degree in emergency preparedness,” he told BusinessWest. “Because, when something happens, people revert to what they know best. Doctors and nurses know how to take care of patients — two at a time, 10 at a time, it’s pretty much the same concept. That’s why hospitals respond so well to these events — they’re used to it. They deal with stressful situations all day long.”

In a disaster situation, says Jim Keefe (left, with Emergency Preparedness Coordinator Bob Moore), Holyoke Medical Center relies first on the accurate assessment and triage performed at the scene.

Gawande echoed that sentiment, noting that events in Boston happened too quickly for any well-practiced disaster plan to fall into place. Dr. Stanley Ashley, chief medical officer at Brigham and Women’s Hospital, told his colleague that “I mostly let people do their jobs.” And without being called, scores of doctors, nurses, and other staff just showed up at the hospital, ready to do what they knew how to do.
Yet, no hospital downplays the importance of planning for a mass-casualty event and then playing out their strategies during periodic drills — a challenge, given that no two scenarios are the same.
“The response is based on the nature of the event,” said Dr. Neil Rathlev, chair of Emergency Medicine at Baystate Medical Center. “With what happened in Boston, clearly trauma surgeons would play a role at the forefront of managing these victims. With a flu pandemic, it would be people from infectious diseases. With a fire like in West, Texas, there would likely be trauma surgeons and toxicologists” because of the toxicity of the chemicals in the fertilizer plant.
But there are similarities in each case, too. Baystate, like most hospitals, follows an incident command system in which emergency responders, police, fire, and other officials set up a command center near the disaster site and communicate with area hospitals about how many patients each is able to accept. Baystate, being the region’s only level 1 trauma center, would receive the most critically injured.
“We implement what we call our disaster plan — all hands on deck,” Rathlev said, meaning no one is allowed to leave, and additional medical professionals are called in. It also means sending home patients who don’t need beds, canceling non-urgent procedures, and clearing out the emergency room as much as possible, moving patients already admitted there to other beds in the hospital.
James Keefe, vice president of Inpatient Services at Holyoke Medical Center, said that facility follows a similar policy of not letting anyone go home during a crisis.
Meanwhile, “we rely on a lot of accurate assessment and triaging outside the hospital at the scene, and we provide resources according to our availability here. If we were going to receive a large number of injured, we would say, ‘don’t start any more elective surgeries. We need the operating rooms empty; don’t put another case in there.’”
In short, once incident commanders let hospitals know how many patients need care, each hospital must make a call based on its capacity. “And every day is different for us,” Keefe said. “We could have the emergency room jammed with 100 patients that day, or it could be empty.”
Planning for a contingency no one can really predict — after all, who foresaw a tornado touching down in Springfield two years ago? — may seem like an impossible task, but hospital leaders say it’s necessary. One look at the TV on Patriots’ Day demonstrates why.

Prepare for the Worst
“Speaking of the tornado, we’ve had our fair share of practice here — I’ve been here four years, and we’ve had three major events,” Rathlev said, referring to the twister, last November’s natural gas explosion in downtown Springfield, and the freak October 2011 snowstorm, which in many ways was more challenging for the hospital than the other two scenarios. “Everyone lost power, and we were inundated with patients who came here needing to plug in ventilators, home oxygen, BiPAP and CPAP machines. They came here because we had backup power.”
Tom Lynch, Baystate’s chief of Security, explained that the hospital has an emergency-planning committee — a multidisciplinary team of employees that includes physicians, other providers, and support staff — and part of the team’s role is to examine all disaster possibilities and try to determine which are most likely to occur locally. “We take that as a starting plan.”
He explained that regulatory agencies dictate some of the things that all hospitals have to do, including the exercise of at least two drills per year. “One has to be a mass-casualty drill, and it has to be community-based; that is the key. The whole idea is to have the involvement of public safety. It’s important for people inside the hospital to know who the outside players are, and for people on the outside to know what we’re doing. It makes it easier to communicate.”
Afterward, Lynch explained, the various players break down what happened during the drill. “It’s helpful to have people sit down in a room, see what we’re doing, and make suggestions about ways to improve it.
“We try to take advantage of every opportunity to learn something, even if it’s outside of our scheduled drills,” he continued. “If a situation presents itself, we say, ‘if it had gone to the next level, how would we handle it?’”
He gave two examples of using real-world, non-crisis situations to simulate emergencies. One was the opening of Baystate’s MassMutual Wing. When patients were moved into that area, the hospital essentially ran the transition like an evacuation drill. “We had observers come in from the city and from the Department of Public Health,” he explained.
Then, when the hospital opened its new Emergency Department, it ran a similar drill when moving patients. “When we had to close in one area and open in another area, it’s a great opportunity for a planning session in real time,” Lynch said. “Again, we had people come in from the outside to evaluate how we did that. Those are the kinds of things that build confidence and skills and allow you to work with people in the community. Then, in the event of some kind of issue, we feel like we have a place to start, and we know what to do.”

Brian Rust says strategies and drills are important, but most critical are caregivers who know what to do in a crisis.

Specific considerations come into play depending on the emergency, Rathlev said, from decontamination in the case of a chemical explosion to the possibility that some victims will arrive at the hospital on their own, not by ambulance. “You have to secure the perimeter of the hospital and not let anyone in unless you’re sure they’ve been adequately decontaminated. Once that happens, they can be brought in.”
Hospitals also must prepare for an inflow of concerned family members, as well as media members, who want to know what’s happening at every turn. “It’s all very systematic, and we practice it on a regular basis,” Keefe said. Those practices often take the form of drills that are unannounced to virtually all participants until they launch, followed by a debriefing and discussion period involving all stakeholders.
Meanwhile, the hospital is constantly monitoring medical trends as part of its planning, since an emergency can conceivably take the shape of a widespread pandemic, not just a localized disaster.
“Every year, we review our policies and procedures, and this year we predicted a tough flu season,” he said, noting that flu cases were showing up earlier than usual, in October, and vaccines were proving ineffective for more than one-third of recipients. The situation never became too serious, but hospitals were alert to the possibility.
“The Department of Public Health asked us to test our ability to handle an influx of flu patients, but we do that anyway,” Keefe said. “If we know we’re going to get a large flu population, we’d open up more beds to take care of the less-ill population; we’d look for alternate locations to treat patients besides the ED.”

Hope for the Best
Rust noted that Cooley Dickinson, like virtually all acute-care hospitals, conducts drills regularly. “We try to plan for everything and anything, but the bottom line is, no matter what it is, it’s sort of the same response. Whether we have a large number of patients come in with a contagious disease or a large number with burns, it’s all about caring for patients.”
Rathlev noted that the larger hospitals in Boston quickly admitted around 25 or 30 patients each, and emergency response personnel worked very quickly to distribute all the injured who needed hospital care — about 140 in all. That kind of response is a reflection of both intensive planning and, as Gawande noted in the New Yorker, caregivers who simply knew what had to be done.
“There is a reason to have plans. That’s important. But that’s not the most important thing; to me, it’s having people who are available,” Rust said, noting that it can be a challenge to mobilize the entire hospital at once, and Cooley Dickinson is working on improving its notification system to manage it more quickly. Still, said all those BusinessWest spoke with, once word of a crisis gets out, medical professionals don’t need much prodding.
“People in our line of business would be rushing to help,” Keefe said. “We would have a hard time keeping people away; they’d want to come. I’m sure Mass General had people coming out of the woodwork — interns, residents, fellows … they want to help. Those guys deal with traumas on a daily basis.”
Rathlev isn’t surprised that disaster management has a high profile right now. “Since 9/11, interest in the public eye has somewhat waned, and now it’s obviously back at the forefront, given what happened in Boston,” he said. “I think it’s very important to teach young medical students and doctors how to manage these situations. The fire in West, Texas, the bombings in Boston … they could happen anywhere. That’s one lesson you have to come away with.”
People often have a short attention span regarding disaster preparedness, Rust agreed, expecting public interest, just like after 9/11, to spike and then fade — except for the people, like him, who are tasked with thinking about it all the time.
“Like everything else, it’s important right after something happens, and then the interest begins to wane and takes a back seat,” he said. “Everyone is so busy dealing with today and yesterday that it can be a challenge getting people thinking about tomorrow.”
But considering the various possibilities is critical, he continued, because large-scale events can occur at any moment. “We know something could happen. Whether it’s a bus tipping over or a dramatic terrorist attack, there’s no longer that shock.”
And, as Boston demonstrated, it won’t be shocking when doctors, nurses, and other caregivers spring into action immediately.
“It’s really that simple,” Rust said. “When we look at the concept of emergency preparedness, it goes back to what you do every day — just on a larger scale. It comes down to having people who know what to do every day, so they can do it any day.”

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